Kathryn Jean Lucas, MD |
|
|
Kathryn Jean Lucas, MD |
|
Use your browser's PRINT command to
print this page
|
K. Jean Lucas, M.D. |
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I hereby authorize ____________________________________________ (PROVIDER) to release and forward my medical chart including machine readable medical and demographic data to Dr. K. Jean Lucas. I understand that this authorization may be revoked by me at any time, except to the extent that action has been taken in reliance on this authorization. PROVIDER, its shareholders, officers, directors, employees, and physicians are hereby released from any liability for disclosure and release of my medical records to the extent indicated and authorized herein.
|
__________________________________ Patient Name (please print)
|
___________________ Date of Birth
|
|
__________________________________ Patient Signature
|
___________________ Date of Signature
|
|
__________________________________ Legal Representative/Relation to Patient |
___________________ Date of Signature |
|
Office Use Only |
|
|
Medical Record Number |
|
|
|
|
|
|
|
Send mail to
Seth.Medlin@BeachDoctor.com
with
questions or comments about this web site.
Send mail to Dr. Lucas
lucas@BeachDoctor.com
Copyright ©
1999-2011 K. Jean Lucas, MD, All Rights Reserved
 Click here to start. |
 |
